One Discharge form

To note for Locala Community Rehabilitation Service Kirklees

Adaptations and equipment. Please refer to: Accessible Homes Team, Kirklees Council, Streetscene & Housing, Flint Street, Fartown, Huddersfield HD1 6LG (Tel: 01484 225335) or via Gateway to Care (01484 414933).
Replacement equipment/ repairs. Please contact Medequip 01484 728970
Care home residents If the client is a new permanent resident within the care home or has had a hospital admission and would come under the remit of the Care Home Support Team (falls assessments and physiotherapy), please refer via Locala e-referrals "Care Home"
Manual handling concerns for care companies/ care homes. Please refer to Kirklees Manual Handling team Tel: 01924 431493
Outpatient musculoskeletal physiotherapy (musculoskeletal issues without co existing frailty/ holistic needs) Please refer to:
North Kirklees Physiotherapy Musculoskeletal Outpatients Department, Staincliffe Wing, Dewsbury and District Hospital, Halifax Road, Dewsbury, WF13 4HS
South Kirklees MSK physiotherapy referrals to be made to: Brighouse Health Centre, Lawson Road, Brighouse, HD6 1NY Tel: 01484 728923
Splinting North Kirklees The referral needs to be sent onto the Splinting Service – Long Term Conditions Team, MY Therapy, The Bungalow, Gilcar Way, Castleford WF10 5QS
Orthotic requests South Kirklees- The referral needs to be sent to Orthotic Department, Lower Ground, Huddersfield Royal Infirmary, HD3 3EA
Wheelchairs referrals – please forward onto Calderdale and Kirklees wheelchair services, Unit G7, Navigation Close, Lowfields Business Park, Elland, HX5 9HB Tel: 01422 312729

For repairs: https://rosscare.co.uk/pages/[email protected]%20
Chronic pain referrals: E referral to: Pain Management Solution, Brian Jackson House, 2 New North Parade, Huddersfield HD1 5JP
Addenbrokes assessment: Locala do not provide Addenbrookes assessments as a stand alone assessment to aid consultant diagnosis or to inform DVLA. Please refer to the Kirklees memory service or William Merritt Centre as appropriate for need. Locala only accept requests for Addenbrookes where it is related to a clear rehab goal.
Neurological Physiotherapy Outpatients: (Lower limb, Mobility, No MDT needs, not housebound) The referral needs to be sent to Neuro Out patient Physiotherapy. Please send a letter of referral (there is no set form) to Therapies Admin, Gate 3a , Pinderfields Hospital
Occupational Therapy Out Patients: The referral needs to be forwarded to, Huddersfield Royal Infirmary, HD3 3EA
Learning disabilities: for patients with specialist needs. Please contact 01924 316714/01484 456997.

Kirklees adult learning disability health service - South West Yorkshire Partnership NHS Foundation Trust

Next of kin

Next of kin name:

Next of kin relationship:

Next of kin address:

Next of kin telephone:

Key holder?

Yes

Next of kin email:

Consent to be contacted:

Yes

Care Home Resident

Is the patient a Care Home Resident? *

Yes

If yes, are they are permanent resident in the Care Home? *

Yes

If no, what type of bed is the patient in? ( eg: respite, short stay, D2A) *

Adult Stoma - Greater Huddersfield Only

This service is for the Greater Huddersfield area only

Does the patient usually visit their GP? *

Yes

If yes, please end this referral and contact the Stoma Nurses at Huddersfield Royal Infirmary

Best decison made by (Name and contact number)

Is the patient housebound? *

Yes

If no, please end referral and contact the stoma nurses at Huddersfield Royal Infirmary

Relevant medical history *

Relevant surgical history *

If other, please specify *

Reason for referral *

Optional attachment Upload file

Cardiac Rehab

Criteria

The service is to support and provide care for patients after a “recent” cardiac event.

Myocardial Infarction
Angioplasty/Primary Angioplasty
Cardiac surgery (Coronary bypass, valve repair/replacement)
Support/care Pre cardiac – surgical patients.

Diagnosis on discharge

Is a GTN spray/tablet prescribed?

Yes

If no, please explain why?

Can the patient open the door?

Yes

Past Medical History, if not attaching discharge letter

Attach discharge summary Upload file

Any significant social history

Any additional information

Optional attachment - any further information e.g. echo, please attach Upload file

Ageing Well

Long term condition - patients must meet the criteria below:

The patient has had an unplanned hospital admission due to a long term condition within the last 12 months
The patient is over 18 years old
The patient is taking four or more prescribed medications OR High Intensity User - patient has attended A&E dept / called 999 / attended GP Surgery more than 3 times in 1 months period and the referrer believes that the patient requires an holistic assessment of their heath needs.
Patient meets above description of high intensity user
Patient is over 18 years old

In a home visit, are there any risks to staff? *

Yes Not known

What are the risks? Please provide details of any risks (dangerous dogs, environmental infestations, any history of offenders residing at the property etc.) *

Can the patient open their door? *

Yes

What is the keysafe number? *

The patient consents to contact via:

Skype

What is the patient's email address? *

What is the patient's Skype ID? *

Number of admissions / 999 calls / A&E / GP clinic attendances in the last 12 months: *

Reason for Referral (as related to long term condition or high intensity user): *

Unexplained falls - frequency and any injuries sustained:

Any other relevant information:

Please attach any clinical letters/any other relevant information: Upload file

COPD - NORTH ONLY

Please note

For patients requiring the North Kirklees admission avoidance service for acutely unwell COPD patients please contact the Mid Yorkshire respiratory nurses at Pinderfields Respiratory Office on 01924 541827.

In North Kirklees, Pulmonary Rehabilitation is provided from Midyorkshire Hospitals, not Locala as in Greater Huddersfield.

In order for patients to be accepted into the service they must have a diagnosis of COPD confirmed by spirometry OR a history strongly suggestive of COPD. ·
All patients referred MUST have had a chest x-ray within the last 6 months. ·
All patients must be registered with a GP in the North Kirklees CCG. Patients suitable for referral to the service include those: ·
Who would normally be referred to secondary care but who can be safely assessed in the specialist community multi-disciplinary service. ·
Where the referrer requires specialist input to manage patients with complex COPD ·
Where the patient has dyspnoea disproportionate to disease severity ·
Who may be suitable for surgical intervention such as endobronchial valves/lung volume reduction surgery ·
Who are having frequent exacerbations despite maximum inhaled therapy ·
Who require nebuliser assessment ·
Who have a palliative care need

Spirometry result: Upload file

Chest x-ray report: Upload file

List of current medications/adverse drug reactions/allergies: Upload file

Please attach any clinical letters/any other relevant information: Upload file

Diabetes Specialist Nurse - SOUTH ONLY

Reason for referral *

Patient to be seen in *

Home

Community Clinic

Date of diagnosis *

Type *

1 Pre-conceptual care

Up to date Hba1c and u+e result *

Recent BMI (Body Max Index) *

BG meter in use *

Blood ketone *

Care plan for hypo/hyperglycaemia completed and added to SystmOne? *

Yes

Current Medication *

Please attach any clinical letters/any other relevant information Upload file

Dietetic Outpatients

Criteria Exclusions:

Patients who do not have a Huddersfield GP
Referrals in which the patient is housebound.
Newly diagnosed diabetes or patient who need education to improve glycaemic control – Refer to DESMOND (e-referrals)
Home Enteral Nutrition – signpost to: Huddersfield Community Rehab dietitians.
If GP is Calderdale signpost to Calderdale Gate way to care (Lisa Green – certain Fixby addresses as serviced by her if under Ryddings Hall GP)
Kirklees Learning Disability Services, Fox View Hub, 8 Fox View, Off Halifax Road, Dewsbury, WF13 4AD. Tel: 01924 316714. Email: [email protected]
If you are emailing please let admin know on 01484 456997 that a referral has been made and to expect a referral.
Eating disorders – Suspected or confirmed eating disorders - Email [email protected] using the CONNECT referral form which is available at https://www.leedsandyorkpft.nhs.uk/our-services/yorkshire-centre-for-eating-disorders/
To access weight management via KWS, patients must be: Aged 18+ & Kirklees resident; ready to engage in a programme of change; BMI of 30kg/m2 or above (or BMI ≥ 27 kg/m2 if they are of high risk, black or Asian origin). Kirklees Wellness Service (KWS) , Civic Centre 1, High Street, Huddersfield, HD1 2NF. GP practices can send the completed referral form via NHS.net to [email protected]
Head and neck cancers – signpost to: CHFT Head and Neck cancer team – Sarah Topen, Dietitian, c/o Maxillofacial Dept, Huddersfield Royal Infirmary; HD3 3EA; Telephone: 01484 347072 – only if dietetic problems are directly related to H&N cancer (e.g. such as post treatment long term side effects).
Upper GI (stomach/ pancreatic/liver) cancers - signpost to Niti Rajagopal – CHFT upper GI oncology dietitian (upper GI office, corridor 3; HRI– 01484 356956)
Renal disease
Care home residents with Dementia/ Psychosis with deteriorating mental health status or signs of deteriorating mental health or experiencing a mental health condition which shows signs of escalating risk - signpost referral to Care Home Liaison Team (South West Yorkshire Partnership trust) – tel: 01924 284553 or direct to Helen Morgan- dietitian : Mobile: 07795 092675
Nutritional support with a MUST score=0 -1– redirect back to care home and advise them to implement Low risk MUST care plan i.e. repeat MUST screening monthly

Is the patient housebound? *

Yes - Your referral will be rejected

If other, please specify *

Please provide additional detail to support your reason for referral: e.g. type of diabetes, patient medical history, height, weight *

Please attach the consultant letter here: Upload file

Home Enteral Nutrition - SOUTH ONLY

For information regarding HEN in the NORTH please contact 0844 811 8110 or 01924 541000

Consultant *

Diagnosis *

Reason for referral *

Usual weight (KG) *

Current Weight (KG) *

Height (M) *

Past Medical History *

Relevant Medication *

Is patient aware of diagnosis/prognosis *

Yes

Other professionals involved *

Tube information - reason for placement *

Type of tube in situ *

Tube size (Fr) *

Location of tube tip *

Placement hospital *

Date of insertion *

Plans for replacement *

Spare tube provided? *

Yes

SaLT advice *

Feeding regime and/or oral intake and supplements - nutritional values *

Additional H2O needed *

Patient registered with Nutricia? *

Yes Pump tracking only

Nutricia nurse involved with the patient? *

Yes

Any other relevant information? *

Optional Attatchment Upload file

Kirklees Care Home Support Team

Criteria

New PERMANENT resident to an older persons care home (temporary residents, please refer to GP practice)
Hospital discharge – permanent residents only
Request support for Care Home MDT including Consultant Geriatrician (currently Huddersfield Care Homes only)

Date of admission to care home/discharged from hospital *

Which hospital discharged from and ward *

Is the patient a permanent Care home resident or Temporary? *

Permanent

Temporary

Any other relevant information, please include here *

Residents are usually seen within 2 weeks of receiving the referral by a member of the Care Home Support Team. If you have not heard anything within this time then please call admin team 030 3003 4347.

Nurse-led TB Screening Service

Been on holiday for more than 6 months in any of the countries listed above? *

Has he/she been in the UK for the last 5 years or less? *

Yes

County of birth *

Country arrived from *

Countries lived in last 5 years *

Date of arrival in the UK *

Are they asylum seeking and refugees? *

Yes

Who else have they travelled with? (Please do separate referral(s)) *

What's their country of origin? *

Date of arrival *

Is the patient's main spoken language English? *

Yes

If other, please specify *

Has the patient been treated or tested for TB during their visit to the UK? *

Yes

If yes, please give details *

Blood tests/any other supporting information Upload file

Obstetric Trauma

If patient is unable to consent to the referral, please provide details

Condition - Date of Delivery *

Presenting condition *

3rd Degree Tear Ventouse Shoulder Dystocia

4th Degree Tear Forceps

Any other information

Optional attachment - Please attach any clinical letters/any other relevant information Upload file

Pulmonary Rehabilitation

Pulmonary Rehab from GPs, Acute Trusts and Patients Criteria

Please note: this form is for patients registered with Greater Huddersfield CCG only GP Practices in Greater Huddersfield Pulmonary Rehabilitation Service Referral criteria

Respiratory disease
Independently mobile and no transport required
Must be able to commit to attending Pulmonary Rehabilitation for 16 sessions over 8 weeks
Must be motivated to attend and make changes to their lifestyle
Are happy in a group environment and will actively participate in the programme • have a MRC score of 3 or greater

Exclusion criteria

Acute Left Ventricular Failure (LVF)
Acute cardiac event within last 3 m
onths
Uncontrolled cardiac arrhythmia/angina • Cerebral Vascular Accident/neurological incident within last 3 months
Pulmonary embolus/Deep Vein Thrombosis within last 3 months not receiving treatment • Abdominal Aortic Aneurysm (AAA) > 5.5cm or any AAA with uncontrolled BP
Aortic stenosis
Surgery within 6 weeks
Acute/current psychotic episode
Alcoholism affecting life
Any medical problems preventing exercise or compliance with programme
Attending other rehab programme

Reason for referral/diagnosis *

If not recently recorded in the patient's record, what is the current Medical Research Council Dyspnoea Score Chart (MRC)? *

Not troubled by breathlessness except on strenuous exercise Walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace Too breathless to leave the house, or breathless when dressing or undressing

Short of breath when hurrying or walking up a slight hill Stops for breath after walking about 100m or after a few minutes on level ground

Oxygen saturations % at time of referral *

Is the patient receiving long term oxygen or ambulatory therapy? *

Yes

What is the prescribed Litres / minute for their oxygen therapy? *

Any additional information or comments *

Please provide supporting documents as any missing information may result in a delay in processing your referral

Supporting documents required with this referral - Spirometry result (including print of graphs) Upload file

Respiratory - SOUTH ONLY

Please note

Expected cases of TB must be referred to the Adult Respiratory Consultant within the Acute setting.
Also home visits if requested are nurse visits and are primarily for education.
Interventions in patient’s own homes are limited
GH Respiratory
Patient Details: If contact details are incorrectly input where mandatory the referral cannot be processed

If you are requesting respiratory equipment loan, we are unable to offer same day provision, please take this into account when discharging patients. Please confirm you acknowledge and understand this statement *

Yes

Please specify ward *

Relevant medical information/diagnosis *

Please list 'all' current medications/drug reactions/allergies *

Please attach any clinical letters/any other relevant information Upload file

Tissue Viability - NORTH and SOUTH

Referral criteria

Pressure Ulcers; Category 3,4 and unstageable
Patients with tissue damage who are non-concordant despite having been provided with explanation of implications of non-concordance
Patients with non-healing wounds beyond expected time frame for healing, for example, venous leg ulcers which are failing to heal within 24 weeks
Patients receiving, or to commence
Topical Negative Pressure (e.g.VAC)
Patients receiving, or to commence larvae (maggot) therapy
Options for managing fungating lesions

Medical History *

Please attach any clinical letters/any other relevant information * Upload file

Reason for Referral *

Type of wound *

Duration of wound *

Wound size *

Location of wound *

Tissue type *

Current management *

Exudate *

Wound pain *

Medication *

Allergies *

Waterlow/risk assessment *

Mattress *

Cushion *

Other equipment *

KILT Re-referral request

Date or original referral *

Please confirm the patient is approaching medically well *

Yes

Is the patient medically well for discharge today? *

Yes

Please describe what investigations have taken place since the original KILT referral (including care delivered) *

Please give details on patients mobility *

Please describe patients overnight needs *

Any additonal information

Catheter Hub/Home Catheter Care/TWOC

Is the patient housebound? *

Yes

Urgency *

Within seven days

Non-urgent

Adult Continence Service Referral Information

Is the patient able to attend Short notice appointments *

Yes

Does the patient have palliative and/or End of Life Care Needs? *

Yes

Route of Administration	Acceptance onto caseload
Oral	No. Not undertaken by CNN’s. Care agency to support as necessary.
Intravenous	Not undertaken by CNN’s except for line maintenance.
Topical	Not routinely emollients or medicated creams. Care agency to support as necessary. Medicated creams and emollients will be applied if under a bandage or dressing that is being administered by the CNN. The administration of patched can be accepted onto caseload provided that the care company will not administer.
Rectal	Yes
Vaginal	Yes
Via feeding tube e.g., NG, PEG	Not in North Kirklees – Fresenius provide training to care companies to North Kirklees to enable them to administer. In Greater Huddersfield patients will only be accepted to avoid delays in discharge.
Eye/Ear/Nose drops	Yes. Consider whether the patient would be able to administer using an aid and supply as appropriate.
Intramuscular	CNN’s can administer medicines via intramuscular injection. Locala do not accept referrals for vaccination of housebound patients.
Subcutaneous	CNN’s can administer medicines via sub-cutaneous injection.

One Discharge form

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